Adjunctive immunotherapy with autophagy-promoting agents could potentially shorten the duration of treatment and improve adherence. It could also enable the use of rifamycin-sparing regimens, which would not affect HIV medications. Given the potent effect of induction of autophagy in promoting the intracellular killing of Mtb in vitro[20], therapy with an inducer

of autophagy may prove valuable as a therapeutic strategy for infection with Mtb. Options would include mTOR inhibitors, including rapamycin (sirolimus) and everolimus, both of which are currently licensed for clinical use to prevent transplant rejection. Aerosolized administration of these drugs, possibly in combination with nanoparticles to enable targeting to macrophages, could maximize efficacy and minimize systemic side effects. Another option would be to target the mTOR-independent, D-myo-inositol-1,4,5-trisphosphate (IP3)-regulated pathway which GSK3 inhibitor induces autophagy. Lithium, carbamazepine and sodium valproate, used to treat mood disorders and epilepsy, activate this pathway [84], and may be amenable to use as adjunctive treatment of tuberculosis [85]. Alternatively, targeted administration of autophagy-promoting cytokines, such as TNF-α

and IFN-γ, could prove effective. Indeed, adjunctive immunotherapy for drug-resistant TB with aerosolized IFN-γ has been trialled with some success [86]. Suppression of IL-10 or the Th2 cytokines IL-4 and IL-13 is Ixazomib clinical trial another potential approach to promoting autophagy. Etofibrate Ghadimi et al. demonstrated that infection of peripheral

blood mononuclear cells treated with heat-killed Mtb with lactic acid bacteria (LAB) resulted in decreased secretion of IL-4, IL-13 and IL-10 and increased secretion of IFN-γ, along with increased autophagosome formation [87]. In vivo, oral treatment with lactobacilli may be sufficient to down-regulate the Th2 response, as this has been shown to down-regulate the lung Th2 response in mice [88] and has been found to improve lung immunity in humans [89]. Other approaches to suppressing Th2 cytokines include helminth-derived immunomodulators [90]. Paradoxically, when tuberculosis is treated, patients’ symptoms may worsen, due possibly to increased proinflammatory responses to dead mycobacteria [91,92]. This ‘paradoxical reaction’ can cause serious clinical complications, such as compression of the airways in patients with tuberculosis in neck lymph nodes. The inflammatory response to Mtb is particularly problematic in patients with TB meningitis, and can cause stroke and death. Steroids are used to treat paradoxical reaction and TB meningitis, but are not very effective [93] Autophagy-promoting treatments could potentially limit the production of proinflammatory IL-1β[29] yet promote the clearance of dead mycobacteria, and thereby reduce the overactive inflammatory response.